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October 6, 2021 Weekly Issue

PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports, and more. Past issues of the PSNet Weekly Update are available to browse. WebM&M presents current and past monthly issues of Cases & Commentaries and Perspectives on Safety.

This Week’s Featured Articles

Ceschi A, Noseda R, Pironi M, et al. JAMA Netw Open. 2021;4(9):e2124672.
Medication reconciliation at hospital discharge can result in reduction of adverse events when the patient returns to the community. This study measured the effect of medication reconciliation performed at admission to hospital on subsequent health care outcomes. For patients ages 85 years and older, taking more than 10 medications at hospital admission, or both, medication reconciliation at admission did not have an impact on 30-day readmission to hospital.
Holmgren AJ, Bates DW. JAMA Netw Open. 2021;4(9):e2125173.
Hospitals participating in the voluntary Leapfrog program must publicly report data on several quality measures. Hospitals that participated in the Computerized Provider Order Entry (CPOE) Evaluation Tool, which measures medication safety, had a mean score of 59.3% at baseline. Hospitals that received negative feedback showed greater improvement than hospitals that received positive feedback, demonstrating the utility of public reporting in improving quality.
Kwok CS, Bennett S, Azam Z, et al. Crit Pathw Cardiol. 2021;20(3):155-162.
Misdiagnosis of cardiovascular conditions can lead to serious patient harm. This systematic review found that misdiagnosis of acute myocardial infarction (AMI) occurs in approximately 1-2% of cases, and AMI is commonly diagnosed as other heart conditions, musculoskeletal pain, or gastrointestinal disease. The authors suggest that there are opportunities to reduce cases of missed AMI with better education about atypical symptoms and improved training of electrocardiogram interpretation.

Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.

Maternal safety is threatened by systemic biases, care complexities, and diagnostic issues. This issue brief explores the role of diagnostic error in maternal morbidity and mortality, the preventability of common problems such as maternal hemorrhage, and the importance of multidisciplinary efforts to realize improvement. The brief focuses on events occurring during childbirth and up to a week postpartum.
Bosson N, Kaji AH, Gausche-Hill M. Prehosp Emerg Care. 2021;Epub Jul 14.
Pediatric medication administration in prehospital care is challenging due to the need to obtain an accurate weight and calculate dosing. The Los Angeles County emergency medical services implemented a Medical Control Guideline (MCG) to eliminate the need to calculate the dose of a commonly administered medication. Following implementation of the MCG, dosing errors decreased from 18.5% to 14.1% in pediatric prehospital care.
Holmgren AJ, Bates DW. JAMA Netw Open. 2021;4(9):e2125173.
Hospitals participating in the voluntary Leapfrog program must publicly report data on several quality measures. Hospitals that participated in the Computerized Provider Order Entry (CPOE) Evaluation Tool, which measures medication safety, had a mean score of 59.3% at baseline. Hospitals that received negative feedback showed greater improvement than hospitals that received positive feedback, demonstrating the utility of public reporting in improving quality.
Ceschi A, Noseda R, Pironi M, et al. JAMA Netw Open. 2021;4(9):e2124672.
Medication reconciliation at hospital discharge can result in reduction of adverse events when the patient returns to the community. This study measured the effect of medication reconciliation performed at admission to hospital on subsequent health care outcomes. For patients ages 85 years and older, taking more than 10 medications at hospital admission, or both, medication reconciliation at admission did not have an impact on 30-day readmission to hospital.

King AE, Gerolamo AM, Hass RW, et al. J Allied Health. 2021;50(3):175-181.

Teamwork is essential for effective care coordination and patient safety. This study found that this specific educational intervention (TeamSAFE, which consisted of an online learning module and in-person interprofessional teamwork simulations) for medical, nursing, and allied health students improved knowledge of teamwork skills, increased understanding of the roles and responsibilities of different health professions, and the importance of patient safety.  
Hu X, Casey T. J Adv Nurs. 2021;77(9):3733-3744.
Speaking up about concerns is essential to improving safety, but prior research has found that many healthcare workers do not feel comfortable speaking up. In this study, staff members from a disability healthcare organization in Australia responded to a questionnaire regarding organizational identification and culture of safety. Findings highlight the importance of organizational identification and management commitment to safety and psychological safety in promoting speaking up behaviors.
Bouwman R, Bomhoff M, Robben PB, et al. J Patient Saf. 2021;17(7):473-482.
When appropriately responded to and addressed, patient complaints may help prevent adverse events. In this study of patient complaints filed with the Dutch Healthcare Inspectorate, researchers investigated how patients expected their complaint would impact healthcare quality, whether patients and regulators had similar expectations, and if expectations are different whether the complaints are clinical or nonclinical in nature. Results show a mismatch between expectations of patients and regulators.
Ranum D, Beverly A, Shapiro FE, et al. J Patient Saf. 2021;17(7):513-521.
This analysis of medical malpractice claims identified four leading causes of anesthesia-related claims involving ambulatory surgery centers – dental injuries, pain, nerve damage, and death. The authors discuss the role of preoperative risk assessment, use of routine dental and airway assessment, adequate treatment of perioperative pain, and improving communication between patients and providers.
Weenink J-W, Wallenburg I, Leistikow I, et al. BMJ Qual Saf. 2021;30(10):804-811.
This qualitative study explored the impact of published inspection frameworks on quality and safety in nursing home care, dental care, and hospital care. Respondents noted the importance of the inspection framework design, the role of existing institutional frameworks, and how the frameworks can influence quality improvement across various organizational levels.
Gluschkoff K, Kaihlanen A, Palojoki S, et al. Safety Sci. 2021;144:105450.
Organizational culture can influence whether or not clinicians report patient safety incidents. Nurses were surveyed about their experiences with non-reporting of health information technology (HIT)-related safety incidents. Approximately half of respondents indicated that they did not file a report when encountering an HIT-related incident. The authors suggest strengthening organizational culture may increase reporting.
Burke HB, King HB. BMJ Open. 2021;11(9):e040779.
This study of US primary care physicians tested their patient safety and quality knowledge. Five topic areas were assessed: 1) patient management, 2) radiation risk, 3) general safety and quality, 4) structure, process, and outcome, and, 5) quality and safety definitions. The average score was 48% correct, indicating additional education in patient safety and quality for practicing primary care physicians is needed.
Kukielka E. Patient Saf. 2021;3(3):18-27.
Trauma patients, who often suffer multiple, severe injuries and who may arrive to the Emergency Department (ED) unconscious, are vulnerable to adverse events. Using data reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers in this study evaluated the safety challenges of caring for patients presenting to the ED after a motor vehicle collision. Common challenges included issues with monitoring, treatment, evaluation, and/or documentation, patient falls, medication errors, and problems with transfers.
Stovall M, Hansen L. Worldviews Evid Based Nurs. 2021;18(5):264-272.
Clinicians who are involved in a patient safety incident often experience significant emotional consequences. This study found that nurses involved in an patient safety incident resulting in patient death were more likely to change jobs, consider leaving the profession, and have suicidal ideation, compared to nurses involved in incidents that did not result in patient harm.
Fernández‐Aguilar C, Martín‐Martín JJ, Minué Lorenzo S, et al. J Eval Clin Pract. 2021;Epub Aug 11.
Heuristics, or the use of mental shortcuts based on experience or trial and error that allow clinicians to quickly assess or diagnose a problem, can sometimes result in misdiagnosis. Three types of heuristics are explored in this study of primary care diagnostic error: representativeness, availability, and overconfidence. While a diagnostic error was identified in nearly 10% of cases, there was no significant correlation between the use of heuristics and diagnostic error.
Waddell AE, Gratzer D. Can J Psychiatry. 2021:070674372110365.
Safety gaps in mental health care offers a limited view if focused primarily on patient suicide. This commentary calls for Canadian psychiatric professionals to examine the safety of their patients from a system perspective to develop a research and practice improvement strategy.
Liu LQ, Mehigan S. AORN J. 2021;114(2):159-170.
Surgical safety checklists (SSC) have been shown to improve outcomes, but effective implementation remains a challenge. This systematic review evaluated the effectiveness of interventions to increase compliance with the World Health Organization’s SSC for adult surgery. Interventions generally fell into one of four categories: modifying the method of SSC delivery, integrating or tailoring the tool for local context, promoting awareness and engagement, and managing organizational policy. Study findings suggest that all approaches resulted in some improvement in compliance.
Kwok CS, Bennett S, Azam Z, et al. Crit Pathw Cardiol. 2021;20(3):155-162.
Misdiagnosis of cardiovascular conditions can lead to serious patient harm. This systematic review found that misdiagnosis of acute myocardial infarction (AMI) occurs in approximately 1-2% of cases, and AMI is commonly diagnosed as other heart conditions, musculoskeletal pain, or gastrointestinal disease. The authors suggest that there are opportunities to reduce cases of missed AMI with better education about atypical symptoms and improved training of electrocardiogram interpretation.

Agency for Healthcare Quality and Research. Fed Register. September 21, 2021;86:52471-52473.

This notice calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Nursing Home Survey on Patient Safety Culture Database data collection process. The comment period closes October 21, 2021.

Ridge K. London, England: Crown Copyright; 2021. September 22, 2021.

Overprescribing has attained prominence as a safety issue due to the current opioid epidemic, but it has long reduced medication safety across the spectrum of health care. The report examines the systemic and cultural issues that contribute to overprescribing and recommends a governmental leadership position to drive change and implement deprescribing and other reduction initiatives.

Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.

Maternal safety is threatened by systemic biases, care complexities, and diagnostic issues. This issue brief explores the role of diagnostic error in maternal morbidity and mortality, the preventability of common problems such as maternal hemorrhage, and the importance of multidisciplinary efforts to realize improvement. The brief focuses on events occurring during childbirth and up to a week postpartum.

This Month’s WebM&Ms

WebM&M Cases
Spotlight Case
Florence Tan, PharmD, Karnjit Johl, MD and Mariya Kotova, PharmD |
This case describes multiple emergency department (ED) encounters and hospitalizations experienced by a middle-aged woman with sickle cell crisis and a past history of multiple, long admissions related to her sickle cell disease. The multiple encounters highlight the challenges of opioid prescribing for patients with chronic, non-cancer pain. The commentary discusses the limitations of prescription drug monitoring program (PDMP) data for patients with chronic pain, challenges in opioid dose conversions, and increasing patient safety through safe medication prescribing and thorough medication reconciliation.
WebM&M Cases
Spotlight Case
Linnea Lantz, DO, Joseph Yoon, MD, and David Barnes, MD, FACEP |
A 44-year-old man presented to his primary care physician (PCP) with complaints of new onset headache, photophobia, and upper respiratory tract infections. He had a recent history of interferon treatment for Hepatitis C infection and a remote history of cervical spine surgery requiring permanent spinal hardware. On physical examination, his neck was tender, but he had no neurologic abnormalities. He was sent home from the clinic with advice to take over-the-counter analgesics. Over the next several days, the patient was evaluated for the same or similar symptoms again by his PCP and was seen by the emergency department and urgent care clinics before being admitted to the hospital; however, he was misdiagnosed with Staphylococcal meningitis, and it was not until his third inpatient day when cervical magnetic resonance imaging (MRI) showed a spinal epidural abscess. The commentary discusses the multiple factors leading to erroneous interpretation tests for spinal epidural abscess and the importance of broadening differentials and avoiding premature closure during diagnosis.

This Month’s Perspectives

Alison Stuebe photo
Interview
Alison Stuebe, MD, MSc, is a professor and Division Director for Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology at the University of North Carolina (UNC) at Chapel Hill and the co-director of the Collaborative for Maternal and Infant Health. Kristin Tully, PhD, is a research assistant professor in the Department of Obstetrics and Gynecology at UNC Chapel Hill and a member of the Collaborative for Maternal and Infant Health. We spoke with them about their work in maternal and infant care and what they are discovering about equitable care and its impact on patient safety.
Perspective
This piece discusses an expanded view of maternal and infant safety that includes the concept of whole-person care, which addresses the structural and social determinants of maternal health.
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